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This is VAERS ID 1033155

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1033155
VAERS Form:2
Age:64.0
Sex:Male
Location:South Dakota
Vaccinated:2021-02-11
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Fall, Resuscitation, Endotracheal intubation, Craniocerebral injury

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone, Rosuvastatin, Prevacid, Zetia, ASA, MVI, Nitroglycerin, Metformin, Potassium, Bumex, Apixaban, Omega 3, Metoprolol, Midodrine,
Current Illness: Generalized ischemic myocardial dysfunction, lower leg edema with cellulitis
Preexisting Conditions: Ischemic Cardiomyopathy, Diabetes, Combined Systolic/Diastolic Heart Failure, Edema, Ventricular Tachycardia, Pacemaker, Stroke, Myocardial Infarction, Hyperlipidemia, Hypertension, Obesity, Coronary arteriosclerosis, Paroxysmal atrial fibrillation, Left ventricular thrombus, Cardiorenal Sydrome, Bilateral lower leg cellulitis
Allergies: No known allergies
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Vaccine given in clinic per protocol - patient monitored for 15 minutes, no adverse reactions noted at the time. Patient stated he felt fine following 15 minute monitoring time. Patient left facility- it was later reported that pt had a fall at home. Upon review of pt''s medical record - Pt''s wife had to initiate CPR and call EMS for transportation and life saving measures enroute to the Emergency Room. Pt was intubated as pt was in asystole upon arrival to the ER, ACLS was continued, pt was noted to have a traumatic brain injury from his fall at home, and pt was pronounced dead at 1620.


Changed on 5/7/2021

VAERS ID: 1033155 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:South Dakota
Vaccinated:2021-02-11
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Fall, Resuscitation, Endotracheal intubation, Craniocerebral injury

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone, Rosuvastatin, Prevacid, Zetia, ASA, MVI, Nitroglycerin, Metformin, Potassium, Bumex, Apixaban, Omega 3, Metoprolol, Midodrine,
Current Illness: Generalized ischemic myocardial dysfunction, lower leg edema with cellulitis
Preexisting Conditions: Ischemic Cardiomyopathy, Diabetes, Combined Systolic/Diastolic Heart Failure, Edema, Ventricular Tachycardia, Pacemaker, Stroke, Myocardial Infarction, Hyperlipidemia, Hypertension, Obesity, Coronary arteriosclerosis, Paroxysmal atrial fibrillation, Left ventricular thrombus, Cardiorenal Sydrome, Bilateral lower leg cellulitis
Allergies: No known allergies allergies
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Vaccine given in clinic per protocol - patient monitored for 15 minutes, no adverse reactions noted at the time. Patient stated he felt fine following 15 minute monitoring time. Patient left facility- it was later reported that pt had a fall at home. Upon review of pt''s medical record - Pt''s wife had to initiate CPR and call EMS for transportation and life saving measures enroute to the Emergency Room. Pt was intubated as pt was in asystole upon arrival to the ER, ACLS was continued, pt was noted to have a traumatic brain injury from his fall at home, and pt was pronounced dead at 1620.


Changed on 5/14/2021

VAERS ID: 1033155 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:South Dakota
Vaccinated:2021-02-11
Onset:2021-02-11
Submitted:0000-00-00
Entered:2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011M20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Cardiac arrest, Death, Fall, Resuscitation, Endotracheal intubation, Craniocerebral injury

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amiodarone, Rosuvastatin, Prevacid, Zetia, ASA, MVI, Nitroglycerin, Metformin, Potassium, Bumex, Apixaban, Omega 3, Metoprolol, Midodrine,
Current Illness: Generalized ischemic myocardial dysfunction, lower leg edema with cellulitis
Preexisting Conditions: Ischemic Cardiomyopathy, Diabetes, Combined Systolic/Diastolic Heart Failure, Edema, Ventricular Tachycardia, Pacemaker, Stroke, Myocardial Infarction, Hyperlipidemia, Hypertension, Obesity, Coronary arteriosclerosis, Paroxysmal atrial fibrillation, Left ventricular thrombus, Cardiorenal Sydrome, Bilateral lower leg cellulitis
Allergies: No known allergies allergies
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Vaccine given in clinic per protocol - patient monitored for 15 minutes, no adverse reactions noted at the time. Patient stated he felt fine following 15 minute monitoring time. Patient left facility- it was later reported that pt had a fall at home. Upon review of pt''s medical record - Pt''s wife had to initiate CPR and call EMS for transportation and life saving measures enroute to the Emergency Room. Pt was intubated as pt was in asystole upon arrival to the ER, ACLS was continued, pt was noted to have a traumatic brain injury from his fall at home, and pt was pronounced dead at 1620.

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